Access to Ambulatory Care in Vulnerable Populations

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:07Welcome to Yale Cancer
00:07 --> 00:08Answers with your host
00:08 --> 00:11Doctor Anees Chagpar. Yale Cancer Answers
00:11 --> 00:13features the latest information on
00:13 --> 00:15cancer care by welcoming oncologists and
00:15 --> 00:18specialists who are on the forefront of
00:18 --> 00:20the battle to fight cancer. This week,
00:20 --> 00:21it's a conversation about
00:21 --> 00:23ambulatory care for vulnerable
00:23 --> 00:25populations with Doctor Joseph Ross.
00:25 --> 00:27Doctor Ross is a professor of
00:27 --> 00:29medicine and of public health
00:29 --> 00:30at the Yale School of Medicine,
00:30 --> 00:32where Doctor Chagpar is a
00:32 --> 00:34professor of surgical oncology.
00:35 --> 00:37So you know, maybe we can start off by
00:37 --> 00:39you telling us a little bit more about
00:39 --> 00:41yourself and what it is that you do.
00:41 --> 00:43Sure, the vast majority of my
00:43 --> 00:45time is spent doing research.
00:45 --> 00:47I do what's called health services
00:47 --> 00:49or health outcomes research.
00:49 --> 00:51Thinking about areas in which we
00:51 --> 00:53can improve healthcare delivery
00:53 --> 00:56for patients and populations.
00:56 --> 00:57I also have teaching roles
00:57 --> 00:58and clinical roles.
00:58 --> 00:59I Co lead a fellowship program
00:59 --> 01:01here at Yale and I see patients
01:01 --> 01:02both in the hospital and in
01:02 --> 01:04our primary care clinic.
01:05 --> 01:07So you know that the term health services
01:07 --> 01:09research is one of those that gets
01:09 --> 01:10bantered around quite a bit, and I.
01:10 --> 01:12I think that for a lot of people
01:13 --> 01:14it's still kind of fuzzy in
01:14 --> 01:17terms of what exactly that means.
01:17 --> 01:20Can you shed some light on on what
01:20 --> 01:22exactly your research entails?
01:22 --> 01:24Sure, I think that the term
01:24 --> 01:26the best way to think about health
01:26 --> 01:29service research as a term is that
01:29 --> 01:31it essentially means clinically
01:31 --> 01:32oriented epidemiology research.
01:32 --> 01:35So I was trained as a physician and learned,
01:35 --> 01:36you know, the basics of,
01:36 --> 01:38you know, internal medicine
01:38 --> 01:39over three years of training,
01:39 --> 01:42and then I did a fellowship program.
01:42 --> 01:44In which I learned how to do clinical
01:44 --> 01:46research using large data sources.
01:46 --> 01:49And so I learned the kind of basics of.
01:49 --> 01:51Biostatistics quantitative methods.
01:51 --> 01:54Working with data as well as other
01:54 --> 01:56aspects of clinical research,
01:56 --> 01:57including qualitative research,
01:57 --> 02:00survey methods, and all the like.
02:00 --> 02:02But for the very early parts of my career,
02:02 --> 02:05what I mostly did was leverage.
02:05 --> 02:08Either data that comes from
02:08 --> 02:11hospitals or insurance plans,
02:11 --> 02:12what's called claims data,
02:12 --> 02:14or other survey datasets that are
02:14 --> 02:16collected by the US government
02:16 --> 02:18or other sources to try to
02:18 --> 02:20understand how we can deliver.
02:20 --> 02:22Healthcare better or identify patients
02:22 --> 02:25who aren't getting the services they need.
02:25 --> 02:26So for instance,
02:26 --> 02:29as examples I did one of my very first
02:29 --> 02:31projects that I ever did was to look
02:31 --> 02:33at whether individuals with higher
02:33 --> 02:36incomes are more likely to receive
02:36 --> 02:39cancer preventive care services as well
02:39 --> 02:41as other chronic disease management
02:41 --> 02:44services like care for diabetes or
02:44 --> 02:46care for cardiovascular disease and
02:46 --> 02:48the reason we were looking at that
02:48 --> 02:50question is because we wanted to know.
02:50 --> 02:53Whether high income mitigates
02:53 --> 02:55the relationship between having
02:55 --> 02:57insurance and not because,
02:57 --> 02:57you know,
02:57 --> 02:58obviously not having insurance
02:58 --> 03:00puts people at risk for not
03:00 --> 03:01getting the care that they need.
03:01 --> 03:04So this is just an example of a
03:04 --> 03:06health services research question
03:06 --> 03:07looking at large data sources
03:07 --> 03:09to try to better understand,
03:09 --> 03:10kind of who's at risk for
03:10 --> 03:11falling through the cracks.
03:12 --> 03:14So so that leads to the obvious question,
03:14 --> 03:16what did you find in that research project?
03:16 --> 03:19Are high income people more likely
03:19 --> 03:22to follow screening guidelines?
03:22 --> 03:25Yes, actually. So this question was
03:25 --> 03:28prompted by at the time 15 years ago,
03:28 --> 03:31all of the policy discussions too.
03:31 --> 03:34Put money into what's called health
03:34 --> 03:36savings accounts that patients could then
03:36 --> 03:38use to obtain the care that they need.
03:38 --> 03:39Right? That I don't.
03:39 --> 03:41I don't want to go down the rabbit hole
03:41 --> 03:42of what a health savings account or is,
03:42 --> 03:44but essentially what we wanted to
03:44 --> 03:46know is if people had discretionary
03:46 --> 03:48funds at their disposal,
03:48 --> 03:50would they use it to obtain the appropriate
03:50 --> 03:52health care services that they were due for?
03:52 --> 03:54What we found?
03:54 --> 03:55Not surprisingly,
03:55 --> 03:57is that people with higher incomes
03:57 --> 03:59were far more likely to get
03:59 --> 04:01preventive care services cancer care.
04:01 --> 04:03Diabetes care cardiovascular care as I said,
04:03 --> 04:06but that the that greater income
04:06 --> 04:09did not necessarily mitigate the
04:09 --> 04:11gap that you see between people
04:11 --> 04:13who are insured and uninsured.
04:13 --> 04:15So if you had uninsured people
04:15 --> 04:18with a lot of income or wealth,
04:18 --> 04:19they didn't necessarily obtain services
04:19 --> 04:22at the rate that those people with
04:22 --> 04:24insurance and also those high incomes did.
04:24 --> 04:26So it's we still identified
04:26 --> 04:27this important gap,
04:27 --> 04:29which raised concerns about whether
04:29 --> 04:31people would use their kind of,
04:31 --> 04:32you know what would be considered
04:32 --> 04:33discretionary income appropriately?
04:33 --> 04:35To get health care services
04:35 --> 04:35that they might need,
04:36 --> 04:37yeah. I mean it.
04:37 --> 04:40It certainly raises questions even now,
04:40 --> 04:42in the current policy environment where
04:42 --> 04:44you know people are bantering about you,
04:44 --> 04:47know will be a universal basic income
04:47 --> 04:50as something that we might want to do
04:50 --> 04:53that could improve quality of life
04:53 --> 04:56for people who are at lower incomes.
04:56 --> 04:59Things like expanding health care
04:59 --> 05:02insurance and whether one or both of
05:02 --> 05:04these potential policy interventions
05:04 --> 05:07might make a difference for cancer Care
05:07 --> 05:10now that we know that for the most part,
05:11 --> 05:15screening is is offered under things
05:15 --> 05:17like the Affordable Care Act.
05:17 --> 05:20Do you think that either of these?
05:20 --> 05:22It will make an impact in terms of
05:22 --> 05:24getting screened and after screening,
05:24 --> 05:26will it make an impact in terms of.
05:26 --> 05:27Following through with treatment,
05:28 --> 05:31yeah, those are both great questions.
05:31 --> 05:34I mean what all of the policy literature
05:34 --> 05:36is consistently demonstrated is that
05:36 --> 05:37people who are uninsured are far less
05:37 --> 05:39likely to get care of that they need,
05:39 --> 05:40particularly cancer preventive services,
05:40 --> 05:43where things you know you kind of kick
05:43 --> 05:44the can down the line because of other
05:44 --> 05:47other things in the cost of the care.
05:47 --> 05:49We know that you know just the
05:49 --> 05:51Affordable Care Act in itself through
05:51 --> 05:53the expansion of Medicaid led to
05:53 --> 05:55great inroads and much increased
05:55 --> 05:57rates of cancer prevention services.
05:57 --> 05:59Among people who had been
05:59 --> 05:59previously uninsured,
05:59 --> 06:02so we we know as a policy, you know,
06:02 --> 06:03expanding Medicaid providing
06:03 --> 06:05health insurance is effective.
06:05 --> 06:06The question of the universal
06:06 --> 06:08basic income in, I think,
06:08 --> 06:10gets at you know all of the other
06:10 --> 06:12challenges that individuals face,
06:12 --> 06:13particularly individuals of
06:13 --> 06:16lower means to obtain care.
06:16 --> 06:17Taking time off from work.
06:17 --> 06:19The transportation to get to the hospital.
06:19 --> 06:19This you know,
06:19 --> 06:21the the expenses of you know making
06:21 --> 06:23sure that someone is there to to
06:23 --> 06:24provide childcare or eldercare
06:24 --> 06:26you know if you as an individual
06:26 --> 06:28are are providing those services.
06:28 --> 06:30So you know the the safety net in
06:30 --> 06:32the in the US is not strong and we do
06:32 --> 06:34need to think about ways to enable
06:34 --> 06:35people to get the care that they need.
06:36 --> 06:39You know one other. One of the questions,
06:39 --> 06:43especially in the states that have
06:43 --> 06:45not expanded Medicaid. There's.
06:45 --> 06:49And perhaps one of the reasons why they
06:49 --> 06:51haven't is the question of, well, what?
06:51 --> 06:53What are the ramifications
06:53 --> 06:56to the rest of society?
06:56 --> 07:01Because if if we you know,
07:01 --> 07:04try to provide a universal basic
07:04 --> 07:06income where we try to provide
07:06 --> 07:10universal health insurance or other.
07:10 --> 07:16City social safety net kind of provisions.
07:16 --> 07:19Essentially somebody's got to pay for that,
07:19 --> 07:23and so people often use that as an
07:23 --> 07:26argument against those kinds of policies.
07:26 --> 07:29Has anybody looked at the ramifications
07:29 --> 07:33in terms of the overall cost to society?
07:33 --> 07:34In other words,
07:34 --> 07:37if people actually did get earlier
07:37 --> 07:40cancer care which tends to be more cost
07:40 --> 07:42effective than getting cancer care
07:42 --> 07:45at the end of life when it really you
07:45 --> 07:47don't get as much bang for your buck,
07:47 --> 07:51the ramifications on society as a whole,
07:51 --> 07:53and whether these kinds of policies
07:53 --> 07:55in fact may be cost effective.
07:57 --> 07:59It's a really interesting question,
07:59 --> 08:00you know, and I think you can
08:00 --> 08:02think about it in two ways.
08:02 --> 08:05Sort of like what's cost effective versus
08:05 --> 08:08kind of what's morally ethically right.
08:08 --> 08:10There was a faculty member at Yale for a
08:10 --> 08:12number of years named Elizabeth Bradley,
08:12 --> 08:14who did a lot of work trying
08:14 --> 08:16to understand across countries.
08:16 --> 08:19When you look at social safety Nets
08:19 --> 08:22and broaden it to even look beyond.
08:22 --> 08:24Healthcare to education and other
08:24 --> 08:25caregiving services and you
08:25 --> 08:27know elder care and you know.
08:27 --> 08:29Nurses, nursery school and all
08:29 --> 08:30of those different things that a
08:30 --> 08:32society can provide to its citizens.
08:32 --> 08:35And you add up all the costs and look at
08:35 --> 08:37the associations with life expectancy.
08:37 --> 08:39Or you know years of healthy living.
08:39 --> 08:41You know the US Unfortunately,
08:41 --> 08:42consistently does you know,
08:42 --> 08:44comes in the middle to the lower
08:44 --> 08:45part of the pack, right?
08:45 --> 08:47We we spend a lot on healthcare.
08:47 --> 08:49We spend very little on the kind
08:49 --> 08:51of pre healthcare social care
08:51 --> 08:54services that can lead to a healthier
08:54 --> 08:55population and then we get stuck.
08:55 --> 08:57You know paying a lot for
08:57 --> 08:58you know disease care.
08:58 --> 09:00You know when when when things are a
09:00 --> 09:02little bit too far gone you could say.
09:02 --> 09:03Who knows,
09:03 --> 09:05I would say if it's truly cost effective,
09:05 --> 09:07but we do know that there are other
09:07 --> 09:09models out there that lead to a,
09:09 --> 09:10you know,
09:10 --> 09:12a population or in communities that
09:12 --> 09:14are generally healthier and happier,
09:14 --> 09:15and you know,
09:15 --> 09:17we all have to allocate resources.
09:17 --> 09:18There's not an infinite budget,
09:18 --> 09:19but you know,
09:19 --> 09:20you could argue that there are
09:20 --> 09:22better ways to allocate the amount
09:22 --> 09:23that we're spending today.
09:24 --> 09:28I mean I, I was getting to to that
09:28 --> 09:30kind of point, which is if you look
09:30 --> 09:32at how much we expend on health
09:32 --> 09:34care and any metric that you want
09:34 --> 09:37to look at in terms of health care,
09:37 --> 09:39whether it's you know even things
09:39 --> 09:42like you know infant mortality rate,
09:42 --> 09:43which you would think in the US,
09:43 --> 09:46should be pretty darn good.
09:46 --> 09:49My understanding is that whether you
09:49 --> 09:52look at infant mortality rate or you look
09:52 --> 09:55at other other aspects of of health.
09:55 --> 09:58We we don't do so well and yet other
09:58 --> 10:01countries who spend less do better.
10:01 --> 10:03So you wonder whether that makes
10:03 --> 10:06the argument that we could be doing
10:06 --> 10:08better as a society in terms of
10:08 --> 10:11restructuring how we spend our dollars.
10:11 --> 10:14And getting more bang for our buck.
10:14 --> 10:16Has anybody kind of done any
10:16 --> 10:18experiments to see whether in fact
10:18 --> 10:21in a microcosm we could look at that,
10:21 --> 10:24and whether that actually plays out?
10:24 --> 10:26I I'm thinking of things like,
10:26 --> 10:28you know the Oregon experiment for example.
10:30 --> 10:31Yeah, I mean the Oregon experiment
10:31 --> 10:34is is is a great experiment in
10:34 --> 10:37terms of rolling out and actually
10:37 --> 10:40testing the impact of Medicaid.
10:40 --> 10:42Eligibility, broadening eligibility
10:42 --> 10:44and making people you know
10:44 --> 10:46signing them up as beneficiaries.
10:46 --> 10:49The broader you know other services.
10:49 --> 10:51You know how we compare to other
10:51 --> 10:53countries that I don't know is ever
10:53 --> 10:54been tested and those are things
10:54 --> 10:55that are very difficult to test,
10:55 --> 10:58which is why economists health services
10:58 --> 11:00researchers are constantly trying to
11:00 --> 11:03leverage large data sources to gain insights.
11:03 --> 11:03In this way,
11:03 --> 11:05you know that I that I described
11:05 --> 11:07with that very first study that I
11:07 --> 11:08did the Oregon experiment, though,
11:08 --> 11:10is it really nice example of.
11:10 --> 11:11You know,
11:11 --> 11:14as Medicaid eligibility was being expanded,
11:14 --> 11:16they were randomizing individuals
11:16 --> 11:19you know to get it or not get it
11:19 --> 11:21essentially and looking at the impact on,
11:21 --> 11:22you know, population,
11:22 --> 11:25health type metrics and of course.
11:25 --> 11:26I think not surprisingly,
11:26 --> 11:28found that people were more
11:28 --> 11:30likely to get different.
11:30 --> 11:31You know,
11:31 --> 11:32ambulatory care services like
11:32 --> 11:34cancer prevention type services.
11:34 --> 11:36They were, you know,
11:36 --> 11:39they did better in terms of other outcomes,
11:39 --> 11:41although they also used care more,
11:41 --> 11:42which you know.
11:42 --> 11:44I think some people questioned
11:44 --> 11:47whether that meant you know.
11:47 --> 11:49If just by providing health insurance
11:49 --> 11:51that leads people to to solicit care,
11:51 --> 11:53and on some level that's probably true,
11:53 --> 11:55people have unmet needs when
11:55 --> 11:58they've been uninsured for a while.
11:58 --> 11:59You know the investigators who
11:59 --> 12:01led the Oregon experiment are
12:01 --> 12:03still following out data now years
12:03 --> 12:04later to understand its impact
12:04 --> 12:06of providing insurance to people
12:06 --> 12:08who heretofore had and had it.
12:09 --> 12:11I mean, I think that the whole question
12:11 --> 12:13of moral hazard comes in in terms of,
12:13 --> 12:16you know, if you give people free
12:16 --> 12:18healthcare free into quotes, healthcare
12:18 --> 12:22that they they tend to use it more,
12:22 --> 12:24but one wonders well if you're using it more,
12:24 --> 12:26but you're using it on
12:26 --> 12:27preventative health and and.
12:27 --> 12:30Kind of nipping in the bud problems that
12:30 --> 12:32could be far more costly in the future,
12:32 --> 12:35whether that in the long run actually
12:35 --> 12:39makes more sense in in terms of, you know,
12:39 --> 12:42getting the best bang for your buck,
12:42 --> 12:43you know. Similarly,
12:43 --> 12:45I understand that there have been
12:45 --> 12:49some all be it kind of grassroots
12:49 --> 12:52experiments going on on the West
12:52 --> 12:54Coast looking at Universal basic
12:54 --> 12:57income to see whether a provision
12:57 --> 12:59of universal basic income can.
12:59 --> 13:00Actually improve outcomes.
13:00 --> 13:03Any any data that you know of in
13:03 --> 13:05terms of how that might affect
13:05 --> 13:08health care in those populations.
13:08 --> 13:10Well, you know what I would think
13:10 --> 13:11it would help the most.
13:11 --> 13:14And many of the
13:14 --> 13:15copayments are our health care
13:15 --> 13:17systems imposes on patients, right?
13:17 --> 13:19So you know, for every prescription
13:19 --> 13:20that somebody picks up,
13:20 --> 13:20there's a copayment.
13:20 --> 13:22You know, for every doctors visit,
13:22 --> 13:24there's a Co payment you can
13:24 --> 13:26imagine as people you know
13:26 --> 13:27farther down the income scale.
13:27 --> 13:29People who are less well
13:29 --> 13:30off and more vulnerable to.
13:30 --> 13:31You know unexpected costs
13:31 --> 13:33in their day-to-day life.
13:33 --> 13:35Having you know a quote, UN quote,
13:35 --> 13:37you know basic income can can mitigate
13:37 --> 13:39some of the challenges in obtaining.
13:39 --> 13:40You know, relatively,
13:40 --> 13:43you know needed and necessary care.
13:43 --> 13:44You know one of the things though,
13:44 --> 13:46that I do want to mention in terms of
13:46 --> 13:48you know this concept of moral hazard is
13:48 --> 13:51that as I think as a healthcare system,
13:51 --> 13:53we have to look at it both ways for sure.
13:53 --> 13:55You know patients who are you know,
13:55 --> 13:57newly insured when there's a
13:57 --> 13:59lower cost burden to obtain care.
13:59 --> 14:01They're more likely to, you know,
14:01 --> 14:03go out, go and get services.
14:03 --> 14:04Some of it's going to be needed.
14:04 --> 14:05Some of it may be considered,
14:05 --> 14:07quote, UN quote, unnecessary,
14:07 --> 14:10some of it may be just sort of pent up
14:10 --> 14:12demand because of being previously uninsured.
14:12 --> 14:14But I think as a health care system,
14:14 --> 14:15we also need to look ourselves in the mirror.
14:15 --> 14:17There are, you know,
14:17 --> 14:18a lot of tests.
14:18 --> 14:20Treatments follow up appointments
14:20 --> 14:23that doctors suggest or impose on
14:23 --> 14:25patients that may also not be needed,
14:25 --> 14:27but that we will sort of say,
14:27 --> 14:28well, just in case,
14:28 --> 14:30or just to be sure you know.
14:30 --> 14:32And so we all you know have to be
14:32 --> 14:34better stewards of healthcare resources.
14:34 --> 14:37It's not just on the patients,
14:37 --> 14:39you know who who who may not have the
14:39 --> 14:41expertise that we as clinicians have
14:41 --> 14:43when making a decision about whether to,
14:43 --> 14:46you know, get a test or or or.
14:46 --> 14:46You know,
14:46 --> 14:47get a prescription for a drug
14:47 --> 14:49absolutely couldn't agree with you more,
14:49 --> 14:51and we're going to pick up that
14:51 --> 14:52conversation right after we take
14:52 --> 14:54a break for a medical minute.
14:54 --> 14:56Please stay tuned to learn more
14:56 --> 14:57about access to care with my guest.
14:57 --> 14:59Doctor Joseph Ross.
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16:10 --> 16:12Welcome back to Yale Cancer answers.
16:12 --> 16:15This is doctor Anees Chagpar and I'm joined
16:15 --> 16:17tonight by my guest doctor Joseph Ross.
16:17 --> 16:20We're learning about obstacles when it
16:20 --> 16:23comes to access to care for vulnerable
16:23 --> 16:26populations and and specifically why
16:26 --> 16:30it is that the US health care system
16:30 --> 16:33spends so much money on health care
16:33 --> 16:36and yet the outcomes that we have.
16:36 --> 16:38Don't really match up to that,
16:38 --> 16:41and right before the break, Doctor Ross you,
16:41 --> 16:45you made a really good point, which is that.
16:45 --> 16:48It's not just on the patient,
16:48 --> 16:50it it really is a number of things
16:50 --> 16:53within the system that increase cost.
16:53 --> 16:55So it's not just how much health
16:55 --> 16:58care a given patient uses.
16:58 --> 17:01But the overall cost of the system itself,
17:01 --> 17:07so one area where costs can be quite
17:07 --> 17:10exorbitant is in the cost of drugs,
17:10 --> 17:12and I was hoping that you could
17:12 --> 17:14kind of talk a little bit about
17:14 --> 17:17how it is that drugs get approved.
17:17 --> 17:19I understand that you do some work
17:19 --> 17:22looking at the FDA and how how
17:22 --> 17:23it goes about approving drugs.
17:23 --> 17:25But it seems to me that when a
17:25 --> 17:27new drug comes on the market,
17:27 --> 17:31it's under patent and so tends
17:31 --> 17:34to fetch a higher price tag than
17:34 --> 17:35those that are generics.
17:35 --> 17:38And so I was hoping that you could talk a
17:38 --> 17:42little bit about how the FDA approved drugs.
17:42 --> 17:45How long they're on patent before they become
17:45 --> 17:48generic and the loopholes around that.
17:48 --> 17:50And how the prices of these
17:50 --> 17:52drugs are actually set?
17:52 --> 17:53In other words,
17:53 --> 17:56do we get the same bang for our buck
17:56 --> 17:58or are we being cost effective in
17:58 --> 18:01terms of buying these medications?
18:02 --> 18:04So I I guess this conversation is
18:04 --> 18:05gonna go on until morning is that
18:05 --> 18:08is that the plan if I'm gonna answer
18:08 --> 18:09all those questions in one and
18:09 --> 18:12describe the all the various loopholes
18:12 --> 18:13and market exclusivity periods.
18:13 --> 18:17It's it's a Byzantine maze like,
18:17 --> 18:18you know, set of rules and
18:18 --> 18:20regulations that govern all this.
18:20 --> 18:23But I'll try to sum it up and keep
18:23 --> 18:26it simple when it comes time for,
18:26 --> 18:28you know, a drug sponsor or
18:28 --> 18:30manufacturer to bring a drug to market.
18:30 --> 18:31You know they they.
18:31 --> 18:33They run through a series of steps.
18:33 --> 18:34In in alignment with the FDA,
18:34 --> 18:36you know they they run some
18:36 --> 18:38premarket clinical trials.
18:38 --> 18:41Usually testing you know first
18:41 --> 18:43on animals later on humans,
18:43 --> 18:44they're looking to make sure
18:44 --> 18:46that the the drug is not toxic.
18:46 --> 18:49Not going to cause you know allergic
18:49 --> 18:51reactions that cause you know really
18:51 --> 18:52severe problems once they have sort
18:52 --> 18:54of past those hurdles and they
18:54 --> 18:56you know they have a compound that
18:56 --> 18:57they are ready to test in humans,
18:57 --> 19:00they start running clinical trials.
19:00 --> 19:02Some of them are what's called phase
19:02 --> 19:03two clinical trials. These are.
19:03 --> 19:04Generally,
19:04 --> 19:06a bit smaller trials in patients
19:06 --> 19:07with the disease,
19:07 --> 19:09and those are essentially geared
19:09 --> 19:12towards helping to inform what are
19:12 --> 19:13called pivotal clinical trials.
19:13 --> 19:15The really big kind of what are
19:15 --> 19:17called phase three trials that
19:17 --> 19:19demonstrate that a drug is safe and
19:19 --> 19:21effective for use 'cause those are
19:21 --> 19:23the standards that the FDA uses.
19:23 --> 19:24Essentially, you know,
19:24 --> 19:26two or more clinical trials that
19:26 --> 19:27demonstrate the safety and
19:27 --> 19:30effectiveness of the drug once it
19:30 --> 19:32passes that hurdle in the drug
19:32 --> 19:35is approved for use by the FDA.
19:35 --> 19:37It's available and on the market,
19:37 --> 19:38and sometimes what.
19:38 --> 19:42I guess the way to think about it and
19:42 --> 19:44and the implications for pricing and
19:44 --> 19:46how our country differs from others is,
19:46 --> 19:47you know,
19:47 --> 19:48once that drug is available for use,
19:48 --> 19:51the manufacturer sets the price.
19:51 --> 19:53They can set any price that they want,
19:53 --> 19:56and that drug is then sold, you know,
19:56 --> 19:58through the channels working with,
19:58 --> 20:00you know health insurance payers or
20:00 --> 20:02Medicare that you know makes a decision
20:02 --> 20:04about whether to cover the product.
20:04 --> 20:07And that it's placed on a formulary.
20:07 --> 20:09And when a patient goes to obtain that drug,
20:09 --> 20:11there's usually a copayment
20:11 --> 20:12that they're charged.
20:12 --> 20:14You know, anywhere between you know,
20:14 --> 20:16$5 for a cheaper drug to
20:16 --> 20:1820% of the cost of the drug.
20:18 --> 20:19You know,
20:19 --> 20:21for more expensive specialty
20:21 --> 20:23drugs in the United States,
20:23 --> 20:25depending on the type of drug it is,
20:25 --> 20:28and you know the various pathways that
20:28 --> 20:30went through in the FDA to get approval,
20:30 --> 20:33market exclusivity, can you know,
20:33 --> 20:34range anywhere from?
20:34 --> 20:37Five years to 12 years and by that
20:37 --> 20:40term I mean the time before which
20:40 --> 20:42generic competition can take place.
20:42 --> 20:44So there's really, you know, unfettered.
20:44 --> 20:45No competition.
20:45 --> 20:47You know,
20:47 --> 20:49the company is selling is the only
20:49 --> 20:51manufacturer of the drug for a long time.
20:51 --> 20:53They can raise the price.
20:53 --> 20:54They can double the price.
20:54 --> 20:56They can do whatever they want over
20:56 --> 20:59that time period, and then once a
20:59 --> 21:01generic is available on the market.
21:01 --> 21:04Usually what we see is that until 2.
21:05 --> 21:073 maybe even four generic manufacturers
21:07 --> 21:09are making the same product.
21:09 --> 21:11The price doesn't drop substantially and
21:11 --> 21:14you know, once there's three or more,
21:14 --> 21:16the price is usually 90% of
21:16 --> 21:17whatever what was charged.
21:17 --> 21:19But you know, for a long time before that,
21:19 --> 21:21prices are very high.
21:21 --> 21:23This differs from pricing in
21:23 --> 21:25other countries where you know,
21:25 --> 21:27for instance, in Europe,
21:27 --> 21:29once the drug is approved by
21:29 --> 21:30the European Medicines Agency,
21:30 --> 21:34then each country makes a decision.
21:34 --> 21:36As to how much they'll pay for it,
21:36 --> 21:38and that decision is based on the
21:38 --> 21:40evidence that's presented as part of the
21:40 --> 21:42clinical trial data that support its use,
21:42 --> 21:45they do something that are called
21:45 --> 21:47cost effectiveness analysis where they
21:47 --> 21:49determine essentially the quality
21:49 --> 21:51adjusted life year benefit of the
21:51 --> 21:53drug they use that you know the
21:53 --> 21:55expected benefit to set the price,
21:55 --> 21:57and then they negotiate with the company to,
21:57 --> 21:59you know, to essentially pay for the
21:59 --> 22:01value they are receiving.
22:01 --> 22:02That never happens.
22:02 --> 22:04In the US, you could have a
22:04 --> 22:07drug that costs $50,000 a year.
22:07 --> 22:08That saves a person's life.
22:08 --> 22:10It may be, you know,
22:10 --> 22:1280% reduces the you know the death
22:12 --> 22:14from a particular cancer by 80%.
22:14 --> 22:16Everyone wants to pay for that drug.
22:16 --> 22:19It's great value even though it's expensive.
22:19 --> 22:21You could also have a $50,000 year drug
22:21 --> 22:24that has a marginal impact and you,
22:24 --> 22:26but you pay the same price because
22:26 --> 22:28the company is the is is kind of
22:28 --> 22:30who setting the terms so in in the
22:30 --> 22:33US price is unconnected to value,
22:33 --> 22:35whereas in a lot of the world it is.
22:35 --> 22:38And I think that we would be much better off.
22:38 --> 22:40As a healthcare system,
22:40 --> 22:43broadly and as a society more narrowly,
22:43 --> 22:45if we tried to better incorporate
22:45 --> 22:47expected value into these equations
22:47 --> 22:49for what we're going to pay,
22:49 --> 22:51I think you know we in the United States,
22:51 --> 22:53you know the general societal
22:53 --> 22:56mindset is we're we're willing to
22:56 --> 22:58pay for therapies that are life
22:58 --> 23:00changing and extremely beneficial.
23:00 --> 23:03The problem is that lots of things are not,
23:03 --> 23:06but they get advertised and promoted very
23:06 --> 23:09heavily such that people believe them.
23:09 --> 23:11To be more effective than they actually are.
23:12 --> 23:14Yeah, and I think that you know health
23:14 --> 23:17care is one of these spaces where
23:17 --> 23:20it's really difficult because there
23:20 --> 23:23is an information asymmetry between
23:23 --> 23:26the consumers and the providers.
23:26 --> 23:29And The thing is that it is so important,
23:29 --> 23:31right? People will say I will
23:31 --> 23:34pay anything for my health,
23:34 --> 23:37except they may not know how much
23:37 --> 23:38benefit they're actually getting
23:38 --> 23:41because of this information asymmetry,
23:41 --> 23:43because they don't know what they don't know.
23:43 --> 23:44Is that right?
23:44 --> 23:46Absolutely, and you know,
23:46 --> 23:49this is particularly challenging when
23:49 --> 23:51you know clinical conditions are,
23:51 --> 23:53you know, kind of dire, right?
23:53 --> 23:55Where where there's patients
23:55 --> 23:57trying to make a decision?
23:57 --> 23:58Or worse, their family.
23:58 --> 24:00You know, trying to make a decision
24:00 --> 24:01about what to do for a patient,
24:01 --> 24:03you know who perhaps, had,
24:03 --> 24:05you know, a a metastatic cancer.
24:05 --> 24:06Just as an example, right?
24:06 --> 24:07And you know,
24:07 --> 24:09should we try that last chemotherapy?
24:09 --> 24:11Well, that you know that last
24:11 --> 24:14chemotherapy you know costs, you know 20%.
24:14 --> 24:16You know of that,
24:16 --> 24:18you know that prices is borne by patients,
24:18 --> 24:20and you know how to pay for it.
24:20 --> 24:22You know, we know that medical
24:22 --> 24:24care is the most common reason for
24:24 --> 24:26bankruptcy in the United States.
24:26 --> 24:27Because you know,
24:27 --> 24:29people just spend spend.
24:29 --> 24:31Money that they don't have and you know,
24:31 --> 24:32bear the consequences.
24:32 --> 24:35And if we could have better conversations
24:35 --> 24:39around anticipated benefit, you know this.
24:39 --> 24:40This chemotherapy, you know,
24:40 --> 24:43the likelihood of it extending your loved
24:43 --> 24:46ones life more than six months is X.
24:46 --> 24:47You know,
24:47 --> 24:49as a clinician I have to recommend
24:49 --> 24:52you don't pursue it as opposed to the
24:52 --> 24:54likelihood is you know, you know,
24:54 --> 24:55we think 50% that they're going
24:55 --> 24:57to live longer than six months.
24:57 --> 24:57With this chemo.
24:57 --> 24:58It's worth it.
24:58 --> 25:00You know this this is this is the kind
25:00 --> 25:01of thing we should be spending money on,
25:01 --> 25:04but but all the more makes me so
25:04 --> 25:05frustrated that we're putting patients
25:05 --> 25:08in their families in these decisions.
25:08 --> 25:09You know, in the position to have
25:09 --> 25:10to make these decisions now,
25:10 --> 25:12how much money can they spend,
25:12 --> 25:13right?
25:13 --> 25:15You know that it's just inherently unfair,
25:15 --> 25:17because lots of people don't have the.
25:17 --> 25:19Money to the resources to spend
25:19 --> 25:22and even people who are insured.
25:22 --> 25:26You know there is a a layer of
25:26 --> 25:28some would call it protection.
25:28 --> 25:30Some would call it bureaucracy in
25:30 --> 25:35terms of will the insurer pay for,
25:35 --> 25:38you know drug X if it's on a
25:38 --> 25:40formulary or test X or procedure X,
25:40 --> 25:43all of which tend to be very
25:43 --> 25:46expensive and all of which have
25:46 --> 25:48varying degrees of benefit.
25:48 --> 25:51Relative to risk varying degrees of
25:51 --> 25:55evidence that backs up their efficiency,
25:55 --> 25:58which then raises the question you
25:58 --> 26:02know so often I find people paint
26:02 --> 26:05insurance companies as the quote bad guy,
26:05 --> 26:07they wouldn't approve my test
26:07 --> 26:09without looking at.
26:09 --> 26:11Well, maybe that's because they're
26:11 --> 26:13looking at evidence based guidelines that
26:13 --> 26:15would recommend against those tests.
26:15 --> 26:18So when you do country comparisons,
26:18 --> 26:20I mean people often look at.
26:20 --> 26:22Countries like the UK or like
26:22 --> 26:25Canada where there is a system of
26:25 --> 26:27universal healthcare in the UK.
26:27 --> 26:28It's still a bit too tiered,
26:28 --> 26:31but under the NHSA universal system.
26:31 --> 26:34But they have something like
26:34 --> 26:37Nice which sets provisions based
26:37 --> 26:38on evidence based guidelines.
26:38 --> 26:41So what are your thoughts about
26:41 --> 26:43that in terms of the US system,
26:43 --> 26:46it doesn't seem that we really have a
26:46 --> 26:50robust means of of communicating that
26:50 --> 26:52evidence. Based guidance to patients.
26:52 --> 26:55Yeah, we have no system in place that does.
26:55 --> 26:57You know what's considered?
26:57 --> 26:58Kind of health technology
26:58 --> 26:59assessments like Nice does,
26:59 --> 27:00which is looking at the sort
27:00 --> 27:02of what the bang for the buck.
27:02 --> 27:03You know what? What are you?
27:03 --> 27:05What is the expected benefit?
27:05 --> 27:06How safe is it and what?
27:06 --> 27:08How much are we going to pay for it?
27:08 --> 27:11And I don't want to paint, you know,
27:11 --> 27:14in a naive picture of, you know,
27:14 --> 27:16care in the UK or care in other
27:16 --> 27:19countries in the United States we have
27:19 --> 27:21remarkable proficiency at providing.
27:21 --> 27:22Highly specialized quote,
27:22 --> 27:25UN quote, very expensive care.
27:25 --> 27:28Sometimes that's great and sometimes
27:28 --> 27:31the it's it's, you know it's.
27:31 --> 27:34It leads to these challenging.
27:34 --> 27:35You know cases that we're talking
27:35 --> 27:36about where people are being provided
27:36 --> 27:37to care that they may not need,
27:37 --> 27:40but on the other side of the coin.
27:40 --> 27:41You know when there are,
27:41 --> 27:43you know various restrictive
27:43 --> 27:44budgets in place.
27:44 --> 27:45You know you can have people
27:45 --> 27:47who may benefit from care,
27:47 --> 27:49not receiving it because of
27:49 --> 27:50the rules and regulations,
27:50 --> 27:53and so each set of each system you know
27:53 --> 27:56could stand to have some improvements.
27:56 --> 27:56I mean,
27:56 --> 27:59what you'd really like to see is a UK
27:59 --> 28:02based system with US like funding, right?
28:02 --> 28:04And maybe it doesn't need to be quite
28:04 --> 28:06as much as we spend on healthcare now,
28:06 --> 28:08but you never want to see a patient
28:08 --> 28:09who's responding well to chemo.
28:09 --> 28:10Kind of.
28:10 --> 28:12Hit their 24 month limit,
28:12 --> 28:14which you commonly see in countries
28:14 --> 28:18like the UK and others who may continue
28:18 --> 28:20to still be good responders you know,
28:20 --> 28:22so there's ways that both sets
28:22 --> 28:23of systems can be improved.
28:23 --> 28:25We can be learning from one another
28:25 --> 28:27to you know to eventually get
28:27 --> 28:29towards a more perfect system,
28:29 --> 28:31and right now there's there's lots of
28:31 --> 28:33room and opportunity for improvement.
28:33 --> 28:35Doctor Joseph Ross is a professor
28:35 --> 28:37of medicine and of public health
28:37 --> 28:39at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu
28:43 --> 28:45and past editions of the program
28:45 --> 28:47are available in audio and written
28:47 --> 28:49form at Yale Cancer Center Org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public
28:55 --> 28:57radio. Funding for Yale Cancer Answers
28:57 --> 29:00is provided by Smilow Cancer Hospital.

Information

Access to Ambulatory Care in Vulnerable Populations with guest Dr. Joseph Ross February 27, 2022 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095